When I coach departments and physician practices on improving patient satisfaction, my goal is to exceed patients' expectations—to provide what patients do not even realize they expect. Expressing concern about the patient and showing a genuine interest go a long way to creating high patient satisfaction. While the physician's diagnostic and treatment skills may be superb, patients often have difficulty assessing medical ability, and sometimes clinical outcomes are delayed, possibly for years. Thus, the patient's full experience during the physician visit is important to informing his or her assessment of having received high-quality medical care.

The survey results reported by Thomas et al help to identify a practice gap of not knowing the true impact of physician attire in maximizing patient satisfaction. Physicians and patients have biases about appropriate physician attire, and the white coat has a long and storied connection with medical practitioners. (It also, fortunately, covers many sartorial blunders.) For patients, the white coat exerts a positive placebo effect in some cases and an anxiety-provoking effect in others. The white coat still says “physician.” Many medical schools have a ceremony during which the dean helps students put on their first white coat. We are affected by training, tradition, institutional expectations, and by media portrayals of physicians. It is my impression that physicians portrayed in commercials are more likely to wear white coats and ties (for men) than physicians in television shows. Is there a message here?

To maximize patient satisfaction, should our patients' preferences contribute to our selection of attire during patient care? Younger patients and physicians tend to be less concerned about physician dress than older ones. Many of our dermatologists in training would wear pajamalike surgical scrubs every day if we allowed it, which might be appropriate, as long as the scrubs were changed daily. Repeatedly worn white coats and rarely cleaned neckties carry bacteria.1- 3

To close the practice gap regarding appropriate physician attire, we must understand patients' attitudes and behaviors in response to their encounters with physicians wearing various types of dress. Indirect questions such as “would you recommend this physician to your best friend?” might prove more useful in eliciting the deeper emotional bases of patients' judgments than direct questions about patient preferences. We should become better informed about our patients' expectations of physician attire. Attire-based discussions and educational sessions should be included as part of dermatology's professionalism competency curriculum.

Barring a deeper assessment of patient preferences or proof of danger to patients, another generation might have to mature before a shift in generally accepted physician attire occurs. Barriers to change are several: (1) those of us who never saw physicians without coats and ties are still leading many teaching centers and practices; (2) despite what patients may say when directly queried in surveys, substantial uncertainly exists whether they want their physicians to dress casually; (3) physicians want to be immediately recognized, so the wearing of white coats is likely to persist.

Patient and physician preferences for attire likely vary with geography, number of pediatric patients seen, and the local culture of patient practice. Yet patient safety must always be a consideration, particularly if certain attire increases the risk of potential infection transmission. If we continue to wear the white coat, laundering at least every 3 days has been recommended.3 As long as the white coat has inherent strength and placebo effect, it may not be in patients' interests to abandon it.